The Daily Briefing

News for Health Care Executives

13 strategic nursing priorities for a changing future

November 7, 2011

Recent Advisory Board analysis indicates that if health care leaders do nothing to respond to the forces currently threatening future hospital margins, the typical hospital could face as much as a 19 percentage point drop in operating margins over 10 years. To safeguard future financial health, hospital leaders must collaborate across disciplines to improve revenue, enhance productivity, expand capacity, and thoughtfully manage case mix. Success on these goals relies heavily on nursing, but how can nurse executives navigate the long list of potential strategic opportunities to ensure efforts have the greatest impact on future financial health and care quality?

Identifying nurse executives’ most critical strategic priorities

Building a strategic plan for hospital-based nursing has never been more important—or more challenging. In our conversations with patient care executives, we often see strategic planning efforts encountering one of two pitfalls.

The first is becoming overwhelmed by uncertainty. With new information released daily about emerging payment models, the economy, and political debate in Washington, it can seem overwhelming to distill all the potential strategies and paths into a limited number of strategic priorities. If nurse leaders succumb to the temptation to create a strategic plan for all eventualities and include a laundry list of priorities, then the plan loses a strategic focus. The result is a non-strategic plan that does not serve to guide a nursing organization through the coming market transformation.

The second pitfall is failing to factor in the extent to which health care delivery may change in the coming decade. This transformation will require hospitals to better coordinate care across disciplines within the acute-care setting, create new partnerships across settings of care, and work more closely with patients and their families. To succeed in the future, it will be critical for nurse leaders to integrate these considerations into the strategic roadmap.

To help nurse executives distill larger health system goals into the most pressing, concrete priorities for nursing, the Nursing Executive Center’s 2011-2012 National Meeting series will provide in-depth guidance on crafting a strategic plan for the coming decade. Additionally, the Center will equip members with detailed templates for crafting and customizing a nursing strategic plan for their unique organization. Finally, we will offer detailed best practices to help nurse leaders put their plans into action.

At the core of the Center’s strategic planning work are 13 strategic priorities that should be the focus of nearly every nurse executive’s strategic plan. These 13 strategic priorities are the items that will deliver outsized returns to nurse leaders and their organization as they navigate the changing healthcare landscape. The 13 strategic priorities for nurse executives are:

1. Enhance performance on measures tied to payment
2. Prevent unnecessary readmissions
3. Pay the appropriate dollars per worked hour
4. Flex staffing to actual demand
5. Innovate on the inpatient care staffing model
6. Elevate the role of nurses in the outpatient setting
7. Achieve zero defect for preventable complications
8. Embed risk assessments for utilization into staff workflow
9. Pre-empt unnecessary medical admissions
10. Redistribute siloed patient care tasks to a cross-continuum navigator
11. Drive individual accountability
12. Strengthen interdisciplinary collaboration
13. Position nursing as a best-in-class partner for IT

Attend the national meeting

To learn more about the critical role of each of these priorities and the unique role the nursing organization can play in achieving them, Center members are urged to log in and register for the national meeting. Attendees will receive templates to build a customized strategic plan focused on the 13 strategic priorities and a crosswalk of each priority to Center resources.

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Panel urges hospitals to mandate flu shots

Ethicists question necessity, cost-effectiveness

November 7, 2011

Health care facilities where less than 90% of employees receive annual flu shots should consider mandatory vaccination, according to draft regulations by a federal panel.

About 40% of health care workers receive a seasonal flu shot, MedPage Today reports. CDC data showed that during the 2009 H1N1 epidemic, about 62% of employees received a vaccine.

The recommendations were made by the National Vaccine Advisory Committee's Health Care Personal Influenza Vaccination subcommittee at the American Public Health Association's annual conference. The committee will make recommendations to HHS on how to increase health care worker vaccination rates to 90%, which is a goal of the agency's Healthy People 2020 plan. The subcommittee will release its final guidelines to the full panel by February 2012.

However, subcommittee member and ethicist Chris Feudtner said there are many ethical and financial issues to consider before mandating vaccination. He noted that that there is a lack of evidence that vaccinating hospital staff would reduce patient infections and that few studies have examined the cost-effectiveness of hospital-wide vaccination programs (Walker, MedPage Today, 11/3).

Will physicians 'fire' patients to meet quality measures?

AHRQ council offers ways to mitigate conflict between patient choice, metrics

November 7, 2011

Experts at an Agency for Healthcare Research and Quality (AHRQ) forum last week discussed whether physicians will "fire" noncompliant patients to ensure they meet quality metrics, CQ HealthBeat reports.

According to participants at AHRQ's National Advisory Council forum, as more payers are instituting pay-for-performance programs, patients are becoming increasingly engaged in medical decision making and at times challenging official recommendations.

"I think we're heading towards an inevitable clash," says Lisa Latts, a member of the AHRQ council and WellPoint's vice president for programs in clinical excellence. For example, parents who refuse to follow the recommended vaccine schedule could force physicians out of compliance with immunization benchmarks and impact payments.

As a result, physicians ultimately may "fire" noncompliant patients from their practices, push back against quality-improvement initiatives, and minimize patient empowerment efforts, CQ HealthBeat reports. Some physicians already are "firing" unvaccinated patients, noting that they pose a risk to others and reflect a lack of trust for physicians' medical advice.

To mitigate the conflict, council members suggested altering performance metrics to account for medical advice recommended by the physician but declined by the patient. Some council members also suggested adjusting down performance measures that aim for 100% compliance (Bristol, CQ HealthBeat, 11/4 [subscription required]).

Medical groups release new guidelines for heart patients

Guidelines sketch new recommendations for rehabilitation, medication

November 7, 2011

The American Heart Association (AHA) and the American College of Cardiology Foundation last week released updated recommendations for managing heart disease patients, HealthDay reports.

For the first time, the guidelines, which were published in Circulation, recommend that physicians refer patients to a comprehensive cardiac rehabilitation program after myocardial infarction, stroke, coronary artery bypass graft surgery, or being diagnosed with heart-related chest pain or leg artery blockages. The guidelines also suggest that physicians screen cardiovascular disease patients for depression, which can reduce quality of life and make it difficult for patients to alter other unhealthy behaviors.

The guidelines also updated recommended uses for antiplatelet and anticoagulant medications. According to the guidelines, new drugs—including prasugrel or ticagrelor—can be used instead of clopidogrel in combination with aspirin for stent patients. The guidelines also stress the importance of using statins to lower cholesterol in atherosclerosis patients.

According to HealthDay, implementing the recommendations will improve patients' quality of life, and reduce their risk for surgery, MI, or stroke. "The full implementation of these cardiovascular protective therapies into clinical practice can markedly reduce the risk of death, disability, and health care expenditures due to cardiovascular disease," said Gregg Fonarow, an AHA spokesperson (AHA release, 11/3; Reinberg, HealthDay, 11/3).

Medicare pilot failed to produce quality improvements

Commercial disease management programs also did not contain costs, study finds

November 7, 2011

Commercial disease management programs within Medicare do not improve quality, reduce costs, or decrease hospital and ED visits, according to a study in NEJM.

For the study, researchers from RTI International studied results from the Medicare Health Support Pilot Program, an initiative created in 2003 to test care coordination for Medicare beneficiaries with heart failure and diabetes. Under the pilot program, nurses acted as "health coaches" who worked with beneficiaries to manage their chronic conditions.

Since late 2005, eight companies had participated in the pilot. A total of 242,417 Medicare beneficiaries joined the randomized trial—two-thirds of patients were assigned to the disease-management program, while the remaining participants received standard care.

The results showed that just one of the eight commercial programs helped decrease the number of hospitalizations, while another program helped reduce the rate of ambulatory care hospitalizations. The review also found that none of the programs reduced ED visits.

In addition, just 14 of 40 process-of-care measurements had statistically significant improvements and there was no decrease in Medicare spending over the course of the project. Meanwhile, the disease-management companies were paid about $400 million.

The researchers said disease-management programs in Medicare might not be effective because many beneficiaries with chronic conditions are difficult to manage. Further, the nurse coaches were not integrated into each participant's primary health care team, making coordinating care challenging (Gever, MedPage Today, 11/4; Kling, Medscape Medical News, 11/2; Medical News Today, 11/4).


Moody's: Losing tax breaks a credit negative for Illinois hospitals

Debate over appropriate charity levels creates additional financial uncertainty

November 7, 2011

Losing state property tax exemptions would create additional financial constraints and possibly weaken credit ratings for Illinois not-for-profit hospitals, according to a recent Moody's report.

The Illinois Department of Revenue this summer denied property tax exemptions to three hospitals based on their charity care levels. In September, Gov. Pat Quinn (D) ordered the department to suspend all future rulings that would deny tax-exempt status to not-for-profit hospitals, affording stakeholders more time to define charity care requirements. Meanwhile, U.S. lawmakers also are urging the Internal Revenue Service to re-examine federal tax exemption and charity care guidelines.

According to Moody's, levying property taxes on not-for-profit hospitals would create additional financial constraints, forcing facilities to make additional expense cuts and redesign processes. In addition, the Illinois Department of Revenue's decision created confusion over how much charity care justifies tax-exempt status, adding uncertainty for hospital management, who already are struggling to cope with a difficult economic climate. The report notes that six of the 23 Illinois not-for-profit hospitals in the investment company's portfolio operated at a loss in 2010. 

The report indicates that the effect of lost property tax exemptions on hospital ratings would depend on the impact of increased taxes on a hospital's revenue and performance. It notes that large hospitals would be more able to handle additional tax liabilities than smaller hospitals, which could be forced to close or reduce services (Moody's report, 11/3; Evans, Modern Healthcare, 11/3 [subscription required]).

ONC delays permanent program for accrediting EHR certifiers

New launch date to coincide with Stage 2 final rule

November 7, 2011

The Office of the National Coordinator for Health IT (ONC) is delaying by six months the launch of a permanent program to accredit the certifiers of electronic health records (EHRs), according to a notice published last week in the Federal Register.

Under the 2009 economic stimulus package, health care providers who demonstrate meaningful use of certified EHR systems can qualify for Medicare and Medicaid incentive payments.

Health care providers seeking to meet meaningful use requirements can use EHR systems approved by ONC's authorized testing and certification bodies. ONC previously authorized six temporary ONC-ATCBs that have certified more than 1,000 EHRs.

In January, ONC issued a final rule to establish a permanent certification program for EHR systems and modules. The final rule stipulates that ONC will choose one organization—the ONC-approved accreditor—to accredit groups aiming to become a health IT certification body. In June, ONC designated the American National Standards Institute as the ONC-AA.

The permanent certification program originally was set to replace the temporary program on Jan. 1, 2012. ONC said it decided to delay the launch of the permanent certification program because there currently are not enough accredited health IT entities to manage all EHR certifications.

ONC added that the new launch date for the permanent certification program would coincide with the release of the final rule for Stage 2 meaningful use criteria. According to Modern Healthcare, the delay should have little effect on health care providers attesting to meaningful use (Conn, Modern Healthcare, 11/3 [subscription required]; Mosquera, Government Health IT, 11/2; Pulley, "Health IT Update," NextGov, 11/2).

Weekly review

Key articles from Oct. 31-Nov. 4

November 7, 2011

Missed a day of the Daily Briefing? Here's a quick round-up of top stories and research highlights from last week’s issues.

Deans give med school rankings a failing grade (Oct. 31)

A panel of top medical school deans says popular magazine rankings are a poor gauge of quality, noting that the lists lean on reputation metrics instead of program innovation. More.

Patients sue over hospital 'observation status' (Nov. 4)

A group of patients last week filed a lawsuit challenging a Medicare policy that allows hospitals to place patients under "observation status" for days without admitting them. More. 

Think you know hospitals? Try your luck at 'Jeopardy!'  (Nov. 2)

How well do you know U.S. hospitals? An episode of the TV quiz show "Jeopardy!" last week featured a category dedicated to hospital trivia. Try your luck—just remember to phrase your answer in the form of a question. More.

How a California nurse made $270,000 last year  (Nov. 1)

California's complex regulations around public workers' compensation, overtime, and furloughs led one nurse to triple her regular pay in 2010 and other state medical staff to report significant earnings as well, Bloomberg reports. More.

FDA approves 'game-changing' aortic valve (Nov. 3)

In a move that cardiologists say is a "game changer" for cardiovascular surgery, FDA last week approved a first-of-its-kind artificial heart valve that will offer certain severe aortic stenosis patients a treatment alternative to major surgery. More.

Congress urges IRS to consider hospital tax exemptions (Nov. 1)

As states reconsider not-for-profit hospital tax exemptions, Congress is urging regulators to re-evaluate federal tax exemption and charity care guidelines, the New York Times reports. More.

CMS revises physician pay cut down to 27.4% (Nov. 2)

CMS last week issued final rules for hospital and physician payments in calendar year 2012, outlining a 27.4% cut in physician reimbursement and finalizing new quality metrics. More.

U.S. News ranks 'best diets for healthy eating'

DASH, TLC, and Mediterranean diets top the list

November 7, 2011

U.S. News & World Report last week released its list of top diets for healthy eating, emphasizing the importance of balanced diets that provide enough calories and nutrients.

For the rankings, 22 experts assessed 20 popular diets across seven categories, including safety and nutritional completeness. The Dietary Approaches to Stop Hypertension (DASH) diet topped the list, followed by the Therapeutic Lifestyle Changes (TLC) Diet, the Mediterranean Diet, and the Mayo Clinic Diet.

Click here to view a full list of the rankings (Hiatt,U.S. News, 11/1; Cohn, "Picture of Health," Baltimore Sun, 11/4).

Staffing considerations in the era of accountable care

November 7, 2011

Join the HR Investment Center on Nov. 8 for a webconference detailing early HR strategies for emerging payment and delivery models. This presentation will provide the building blocks for developing a sound and proactive workforce strategy that supports organizations’ broader accountable care initiatives. More.

Daily roundup: Nov. 7, 2011

Bite-sized hospital and health industry news

November 7, 2011

  • California: Kaiser Permanente last week opened its new $550 million hospital in Ontario, the Inland Valley Daily Bulletin reports. The 386,000-square-foot, full-service hospital includes a 36-bed ED. Greg Christian, executive director of the medical center, said the hospital's opening is a milestone because it is the first ED to open in the city in 20 years (Marquez, Daily Bulletin, 11/1).
  • Illinois and Michigan: Novi-based Trinity Health last week announced that it has signed a letter of intent to acquire Chicago-based Mercy Hospital & Medical Center, the Detroit News reports. The potential affiliation would expand Trinity's access to the Chicago market following its purchase earlier this year of Loyola University Health System. The acquisition—which could be complete as early as the spring of 2012—would allow both organizations to continue operating under Catholic religious and ethical directives (Burden, Detroit News, 11/3).
  • Massachusetts: The Eastern Massachusetts Healthcare Initiative plans to release a proposal this week recommending that state hospitals and insurers be allowed to manage their rising costs for three years without additional government control, the Boston Globe reports. The group—which  includes Partners HealthCare and Blue Cross and Blue Shield of Massachusetts—proposes to form a commission of independent experts and stakeholders to oversee cost controls, holding organizations to a 5% annual spending increase after three years. In contrast, state regulators support granting the insurance commissioner the ability to reject insurance rate increases that are based on disproportionate payments to providers (Kowalczyk, Globe, 11/3).
  • Wisconsin: Hospitals in Wisconsin contribute $28 billion and more than 110,000 jobs to the state’s economy annually, a recent Wisconsin Hospital Association (WHA) study found. According to Steve Brenton, president of WHA, "[a]s Wisconsin leaders consider the state's economic priorities and look for ways to create more jobs, it is important to recognize the important role that hospitals have in our state's economic health" (AHA News, 11/3).


FDA reports near-record number of drug approvals in previous year

FDA in fiscal year 2011 approved a near record number of pharmaceutical drugs, many of which were made available to U.S. consumers before they were distributed to other countries, according to a recent agency report.

In the fiscal year that ended on Sept. 30, FDA approved 35 drugs, the second-highest number in the past 10 years. The agency topped that number in 2009 with 37 approvals. Twenty-four of those drugs were released in the U.S. before they became available in other countries, which allowed the U.S. to retain its lead position as the developer of new medicines. The report also showed that 22 of the 35 drugs were approved during the first stage of review. Nearly half of the approved drugs were "significant therapeutic advances" over existing treatments.

According to the New York Times, the report appears to be FDA's response to drug industry observers and stakeholders who have criticized the agency for its slow review and approval system, despite increasing its research spending. Drugmakers have argued that the slowdown impedes innovation, drives up costs, and forces some U.S. companies to move their operations overseas. Meanwhile, some consumer groups say the FDA sacrifices safety for speed and should receive more information from drugmakers during the approval process.

However, FDA officials say the data demonstrates the need for legislation to continue funding the current drug review system. Some drugmakers already have begun lobbying lawmakers to speed up the reauthorization of the Prescription Drug User Fee Act, which funds the FDA drug review process (Yukhananov/Selyukh, Reuters, 11/3; Fox, National Journal, 11/3 [subscription required]; Pecquet, "Healthwatch," The Hill, 11/3; Harris, Times, 11/3).